Safety of Ultrasound-Guided Transversus Thoracis Plane Block in Pediatric Cardiac Surgery: A Retrospective Cohort Study

Regional Anesthesia With Fascial Plane Blocks for Pediatric Cardiac Surgery With Sternotomy: A Narrative Review

Undertreated pain in children who undergo sternotomy for cardiac surgery can lead to cardiopulmonary complications, the development of chronic pain, and long-term maladaptive stress response. Opioids have dose-dependent side effects that may interfere with postoperative recovery. With the increasing availability of ultrasound, regional anesthesia is often included in multimodal analgesic approaches. Fascial plane blocks targeting the intercostal nerves or ventral rami are of particular interest for patients requiring full heparinization for cardiopulmonary bypass as they avoid manipulation of neuraxial and noncompressible paravertebral spaces. This narrative review summarizes the literature on fascial plane blocks for pediatric patients undergoing cardiac surgery via midline sternotomy and may serve as a guide for clinicians. Both prospective and retrospective studies are reviewed, as are prior review articles. We describe individual fascial plane block techniques including the transversus thoracic muscle plane, pectointercostal fascial plane, serratus anterior plane, and erector spinae plane blocks and provide clinical considerations for each block. Additionally, we provide an analysis of individual studies stratified by anterior or posterior approach and block type. The majority of described studies examine single-shot blocks; the existing catheter literature, which includes erector spinae plane block catheters, is also included. Our findings suggest that fascial plane blocks decrease intraoperative and postoperative opioid use, pain scores, time to extubation, and length of stay in the intensive care unit and hospital. Notably, prospective studies in this field are small, typically fewer than 100 patients, and overall include a homogenous patient population, focusing primarily on patients with acyanotic congenital heart defects. Nonetheless, despite the limitations of individual studies, there is substantial evidence to support the use of regional anesthesia, particularly for patients in whom early extubation is planned. There is a need for large, prospective multi-center studies to evaluate the effectiveness and safety of specific single-shot block types, optimal local anesthetic dosing strategies compared to active comparators, and generalizability of results across institutions. Future studies should also consider evaluating the role of regional block catheters for continuous local anesthetic infusion and the inclusion of additional surgical populations, including neonates, patients with cyanotic lesions, and those with longer postoperative mechanical ventilation courses.

Perioperative and Anesthetic Considerations in Vascular Rings and Slings

Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.

Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial

INTRODUCTION

Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure.

METHODS

The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay.

RESULTS

Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption.

CONCLUSION

Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).

Transversus Thoracic Muscle Plane Block For Postoperative Pain in Pediatric Cardiac Surgery: A Systematic Review And Meta-Analysis of Randomized And Observational Studies

OBJECTIVES

Pediatric patients undergoing cardiac surgery usually experience significant surgical pain. Additionally, the effect of poor surgical analgesia creates a pain continuum that extends to the postoperative period. Transversus thoracic muscle plane block (TTMPB) is a novel plane block technique that can provide analgesia to the anterior chest wall. The analgesic role of TTMPB in pediatric cardiac surgery is still uncertain. A meta-analysis was conducted to determine the analgesic efficacy of this procedure.

DESIGN AND SETTING

Systematic review and meta-analysis. PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure were searched to November 2023, and the Grading of Recommendations Assessment, Development, and Evaluation approach was followed to evaluate the certainty of evidence.

PARTICIPANTS

Eligible studies enrolled pediatric patients from 2 months to 12 years old scheduled to undergo cardiac surgery, and randomized them to receive a TTMPB or no block/sham block.

MEASUREMENTS AND MAIN RESULTS

Six studies that enrolled 601 pediatric patients were included. Low-certainty evidence from randomized trials showed that, compared with no block or sham block, TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative modified objective pain score at 12 hours (weighted mean difference [WMD] -2.20, 95% CI -2.73 to -1.68) and 24 hours (WMD -1.76, 95% CI -2.09 to -1.42), intraoperative opioid consumption (WMD -3.83, 95% CI -5.90 to -1.76 μg/kg), postoperative opioid consumption (WMD -2.51, 95% CI -2.84 to -2.18 μg/kg), length of intensive care unit (ICU) stay (WMD -5.56, 95% CI -8.30 to -2.83 hours), and extubation time (WMD -2.13, 95% CI -4.21 to -0.05 hours). Retrospective studies provided very low certainty that the results were consistent with the randomized trials.

CONCLUSION

Very low- to low-certainty evidence showed that TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative pain, opioid consumption, ICU length of stay, and extubation time.

Perioperative and Anesthetic Considerations in Shone's Complex

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Inadvertent Puncture of Dilated Right Ventricle During Transversus Thoracic Muscle Plane Block: Lessons Learnt

ABSTRACT

The transversus thoracic muscle plane (TTP) block is gaining widespread recognition in cardiac surgery, particularly in facilitating fast-tracking. Here, we report a case of inadvertent puncture of the right ventricle (RV) during the administration of ultra sound-guided (USG) TTP block in a 3-year-old child posted for atrial septal defect (ASD) closure and mitral valve repair. We also discuss the care that should be taken to avoid such complications and such cases require extra caution during TTP block.

Transversus thoracic muscle plane block for pain during cardiac surgery: a systematic review and meta-analysis

STUDY OBJECTIVE

The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure.

DESIGN

Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence.

STUDY ELIGIBILITY CRITERIA

Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block.

MAIN RESULTS

Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12 h [weighted mean difference (WMD) -1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference (RD) for achieving mild pain or less (≤3 cm), 41%, 95% CI 17-65) and 24 h (WMD -1.07 cm, 95% CI -1.83 to -0.32; RD 26%, 95% CI 9-37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12 h (WMD -3.42 cm, 95% CI -4.47 to -2.37; RD 46%, 95% CI 12-80) and at 24 h (WMD -1.73 cm, 95% CI -3.24 to -0.21; RD 32%, 95% CI 5-59), intraoperative opioid use [WMD -28 milligram morphine equivalent (MME), 95% CI -42 to -15], postoperative opioid consumption (WMD -17 MME, 95% CI -29 to -5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95% CI 140-314), and intensive care unit (ICU) length of stay (WMD -13 h, 95% CI -21 to -6).

CONCLUSION

Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.

The Year in Review: Anesthesia for Congenital Heart Disease 2022

This review focuses on the literature published during the calendar year 2022 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease (CHD). Four major themes are discussed: enhanced recovery after surgery(ERAS); diversity, equity, and inclusion; the state of pediatric cardiac anesthesiology as a subspecialty in the United States; and neuromonitoring for pediatric cardiac surgery.

An Expert Review of Chest Wall Fascial Plane Blocks for Cardiac Surgery

The recent integration of regional anesthesia techniques into the cardiac surgical patient population has become a component of enhanced recovery after cardiac surgery pathways. Fascial planes of the chest wall enable single-injection or catheter-based infusions to spread local anesthetic over multiple levels of innervation. Although median sternotomy remains a common approach to cardiac surgery, minimally invasive techniques have integrated additional methods of performing cardiac surgery. Understanding the surgical approach and chest wall innervation is crucial to success in choosing the appropriate chest wall block. Parasternal intercostal plane techniques (previously termed "pectointercostal fascial plane" and "transversus thoracic muscle plane") provide anterior chest and ipsilateral sternal coverage. Anterolateral chest wall coverage is feasible with the interpectoral plane and pectoserratus plane blocks (previously termed "pectoralis") and superficial and deep serratus anterior plane blocks. The erector spinae plane block provides extensive coverage of the ipsilateral chest wall. Any of these techniques has the potential to provide bilateral chest wall analgesia. The relative novelty of these techniques requires ongoing research to be strategic, thoughtful, and focused on clinically meaningful outcomes to enable widespread evidence-based implementation. This review article discusses the key perspectives for performing and assessing chest wall blocks in a cardiac surgical population.

Transversus Thoracis Muscle Plane Block in Paediatric Patients Who Underwent Minimally Invasive Closure of Transthoracic Ventricular Septal Defect: A Retrospective Study

Objective

Minimally invasive closure of transthoracic ventricular septal defect (VSD) has been widely used in paediatric patients. This retrospective study aimed to explore the use of transversus thoracis muscle plane block (TTMPB) in the minimally invasive closure of transthoracic VSD in paediatric patients.

Methods

From September 28, 2017, to July 25, 2022, a total of 119 paediatric patients scheduled for minimally invasive transthoracic VSD closure were considered for inclusion.

Results

In total, 110 patients were included in the final analysis. Perioperative fentanyl consumption of the TTMPB group was not different from that of the non-TTMPB group (5.90 ± 1.32 μg/kg vs. 6.25 ± 1.74 μg/kg, p = 0.473). Both the time to extubation and postanesthesia care unit (PACU) stay were significantly shorter in the TTMPB group than in the non-TTMPB group (10.94 ± 10.31 min vs. 35.03 ± 23.52 min for extubation, and 42.55 ± 16.83 min vs. 59.98 ± 27.94 min for PACU stay, both p < 0.001). Furthermore, the postoperative paediatric intensive care unit (PICU) stay in the TTMPB group was significantly shorter than in the non-TTMPB group (1.04 ± 0.28 d vs. 1.34 ± 1.05 d, p = 0.005). Multivariate analysis demonstrated that TTMPB was significantly associated with shorter time to extubation (p < 0.001) and PACU stay (p = 0.001) but not postoperative PICU stay (p = 0.094). Discussion. This study showed that TTMPB was a beneficial and safe regional anaesthesia technique for paediatric patients who underwent minimally invasive closure of transthoracic VSD, although prospective randomized controlled trials are needed to confirm the results.